What are the advantages of complete resection at the time of Transurethral Resection of Bladder Tumor (TURBT) in Muscle-Invasive Bladder Cancer (MIBC)?

Complete Resection at TURBT in Muscle-Invasive Bladder Cancer

A visually and microscopically complete TURBT is associated with improved patient outcomes in muscle-invasive bladder cancer (MIBC), serving as both optimal staging and potentially therapeutic intervention. 1

Primary Advantages of Complete Resection

Improved Survival Outcomes

• Complete TURBT prior to neoadjuvant chemotherapy (NAC) is associated with significantly higher 5-year overall survival (77% vs. 46%) and cancer-specific survival (85% vs. 50%) compared to incomplete resection. 2
• Patients achieving complete resection demonstrate superior recurrence-free survival and muscle-invasive recurrence-free survival on multivariate analysis. 2
• In bladder preservation protocols, complete TURBT as monotherapy achieved cancer-specific survival of 81.9% at 5 years and 76.7% at 15 years in selected patients with negative tumor bed biopsies. 3

Enhanced Treatment Response

• Complete resection enables more accurate pathologic staging, which is essential for treatment selection and risk stratification. 1
• Patients with complete TURBT have lower rates of residual disease at cystectomy (48% vs. 75% with ≥pT2 disease) and trending lower rates of node-positive disease (17% vs. 37%). 2
• Complete resection allows for better assessment of whether patients can pursue bladder preservation strategies, with 61% of complete TURBT patients able to defer radical cystectomy versus only 32% with incomplete resection. 2

Optimal Staging and Risk Assessment

• Adequate resection with muscle in the specimen is mandatory for accurate staging, as the presence of muscularis propria is essential for distinguishing non-muscle-invasive from muscle-invasive disease. 1
• Complete resection allows proper evaluation of depth of invasion, presence of variant histology, and lymphovascular invasion—all critical prognostic factors. 1
• The completeness of resection directly impacts subsequent treatment decisions, including eligibility for trimodality bladder preservation therapy. 1

Technical Requirements for Complete Resection

Resection Technique

• For MIBC, resection should extend deep into underlying detrusor muscle, with specimens sent separately (tumor base and edges) to ensure adequate pathologic evaluation. 1
• The resection must achieve both visual completeness (no macroscopic residual tumor) and microscopic completeness (negative tumor bed biopsies). 1, 3
• Bimanual examination under anesthesia should document tumor characteristics and assess for extravesical extension. 1

Repeat TURBT Indications

• Repeat TURBT is mandatory when no muscle is present in the initial specimen for high-grade disease, when initial resection is incomplete, or when considering trimodality bladder preservation therapy. 1
• For T1 lesions or when adequate staging cannot be determined from the first resection, repeat TURBT within 2-6 weeks is strongly recommended. 1

Role in Bladder Preservation Strategies

Trimodality Therapy Context

• Maximal TURBT is the primary treatment option for cT2, cT3, and cT4a disease when pursuing bladder preservation with concurrent chemoradiotherapy. 1
• Bladder preservation with maximal TURBT and chemoradiotherapy is generally reserved for patients with smaller solitary tumors, negative nodes, no carcinoma in situ, no tumor-related hydronephrosis, and good pre-treatment bladder function. 1
• Complete TURBT before chemoradiotherapy significantly improves 2-year survival outcomes in trimodality protocols. 4

Monotherapy Potential

• In highly selected patients (complete resection, negative tumor bed biopsies, no hydronephrosis, no metastasis), radical TURBT alone can achieve durable cancer control with progression-free survival of 57.8% at 15 years. 3
• TURBT alone can be considered for non-cystectomy candidates, though outcomes are optimized when combined with systemic or radiation therapy. 1, 5

Impact on Neoadjuvant Chemotherapy

Conflicting Evidence on NAC Response

• One retrospective study found complete TURBT associated with improved pathologic response rates and survival after NAC. 2
• However, another study found no association between completeness of TURBT and pathologic complete response (ypT0) or ypT<2 rates following cisplatin-based NAC. 6
• The weight of evidence suggests complete TURBT improves overall outcomes, though whether this represents less aggressive disease biology or therapeutic benefit remains unclear. 2

Practical Implications

• Complete TURBT prior to NAC allows better patient selection for bladder preservation versus immediate cystectomy. 2
• Patients with complete TURBT and subsequent clinical T0 status after NAC are appropriate candidates for active surveillance/delayed intervention protocols. 2

Common Pitfalls and Caveats

Avoiding Incomplete Resection

• Retrospective data shows 70% of patients had incomplete initial resection, with 30% having macroscopic residual tumor and 70% having unresected tumors away from the resection site. 1
• Wide variability in recurrence rates has been attributed to quality of TURBT performed by individual surgeons, emphasizing the importance of surgical expertise. 1
• Cauterization should be minimized to prevent tissue destruction that compromises pathologic evaluation. 1

Patient Selection Considerations

• Complete TURBT is most beneficial in patients with organ-confined disease (cT2-cT3a), smaller solitary tumors, and absence of hydronephrosis. 1, 2
• Patients with ≥cT3 disease, variant histology, or hydronephrosis are less likely to achieve complete resection and may require immediate cystectomy. 2
• Cystectomy should be performed within 3 months of diagnosis if no neoadjuvant therapy is given. 1

Timing and Imaging

• Imaging (CT or MRI) should be performed before TURBT when invasive tumor is suspected to allow better anatomic characterization without interference from post-TURBT inflammation. 1
• Blue light cystoscopy may be helpful in identifying lesions not visible with white light cystoscopy, improving completeness of resection. 1